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Short communication

The impact of body image-related cognitive fusion on eating psychopathology

Inês A. Trindade, M.S. ¹ *

Cláudia Ferreira, M.S., Ph.D ¹

¹ University of Coimbra, Portugal

CINEICC – Cognitive-Behavioral Research Center

* Correspondence concerning this article should be addressed to:

Inês A. Trindade

CINEICC, Faculdade de Psicologia e Ciências da Educação,

Universidade de Coimbra

Rua do Colégio Novo, Apartado 6153

3001-802 Coimbra, Portugal

Email: ines.almeidatrindade@gmail.com

Telephone: (+351) 239851450

Fax: (+351) 239851462

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The impact of body image-related cognitive fusion on eating psychopathology

Abstract

Recent research has shown that cognitive fusion underlies psychological

inflexibility and in consequence various forms of psychopathology. However, the role of

cognitive fusion specifically related to body image on eating psychopathology remained to

be examined.

The current study explores the impact of cognitive fusion concerning body image in

the relation between acknowledged related risk factors and eating psychopathology in a

sample of 342 female students.

The impact of body dissatisfaction and social comparison through physical

appearance on eating psychopathology was partially mediated by body image-related

cognitive fusion. The results highlight the importance of cognitive defusion in the treatment

of eating disorders.

Keywords: Body image-related cognitive fusion; eating psychopathology; body

dissatisfaction; social comparison; mediation analysis.

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1. Introduction

Acceptance and Commitment Therapy (ACT) aims to enhance psychological

flexibility, which refers to “the process of contacting the present moment fully as a

conscious human being and persisting or changing behavior in the service of chosen

values” (Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p.9). One key process that threatens

psychological flexibility is cognitive fusion (Hayes, 2004; Hayes, Strosahl, & Wilson,

1999).

Cognitive fusion can be described as the degree to which an individual interacts

with events considering only their verbal functions rather than their direct ones (Hayes et

al., 1999). This process results in self-identification with one’s thoughts and in inability in

to consider them as part of inner experience (rather than statements of facts) and

consequently taking objective attitudes towards them (Eifert et al., 2009). Therefore, ACT’s

overall therapeutic goal is to promote cognitive defusion and acceptance of inner events.

These strategies are intended to construct a healthy skepticism about one’s thoughts,

enabling a better contact with the present moment (Hayes, 1989) and the individual’s

values (Fletcher & Hayes, 2005).

Eating disorders have been considered an illness of psychological inflexibility, i.e.

the incapacity of behaving flexibly while dealing with negative sensations, thoughts and

feelings (e.g., Merwin et al. 2011). Although scarce, literature has been highlighting

cognitive fusion in eating psychopathology (e.g. Hayes & Pankey, 2002; Ferreira, Trindade,

Duarte, & Pinto-Gouveia, 2013). Also, research has suggested that ACT is effective and

may even achieve better results than regular behavioral interventions in these disorders

(e.g., Butryn et al., 2013; Juarascio, Forman, & Herbert, 2010; Sandoz, Wilson, &

DuFrene, 2011).

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Body dissatisfaction (e.g., Stice, Marti, & Durant, 2011) and unfavorable social

comparisons (e.g., Troop, Allen, Treasure, & Katzman, 2003) represent nuclear risk factors

for eating psychopathology. Nevertheless, although almost all women compare themselves

physically with other women, which at some point triggers feelings of body dissatisfaction

and ranking disadvantage, not all develop eating psychopathology. This seems to imply that

other processes may also be involved in these conditions. We hypothesized that women

who get fused and tangled with thoughts relating to body image have greater tendencies of

developing disordered mechanisms in order to “correct” their body dissatisfaction and

social disadvantage. Therefore, this study tests whether body image-related cognitive fusion

mediates the relationship between main risk factors and eating psychopathology.

2. Materials and methods

2.1. Participants

Participants included 342 female college students (13 to 25 years old) with a mean

age of 17.76 years (SD = 2.63) and 11.40 (SD = 2.46) of years of education. Their BMI

mean was 21.14 (SD = 2.80), corresponding to normal weight values (WHO, 1995).

2.2. Procedures

The research protocol was approved by the Ethics Committees of the educational

institutions enrolled in the study. Participants and their parents (if the subjects were minor)

gave their written informed consent after being assured of the confidentiality and voluntary

character of their collaboration and informed about the aims of the study.

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2.3. Data analysis

Descriptive statistics were used to explore the sample characteristics in study´s

variables and product-moment Pearson correlation analyses were performed (Cohen,

Cohen, West, & Aiken, 2003). Two mediation analyses were conducted according to

Baron and Kenny (1986), in which body image-related cognitive fusion was tested as

mediator on the association of body image dissatisfaction (Model 1) and social comparison

based on physical appearance with peers (Model 2; predictor variables) towards eating

psychopathology (dependent variable).

2.4. Measures

Figure Rating Scale (FRS; Thompson & Altabe, 1991; Ferreira, 2003). The FRS

evaluates body dissatisfaction through a series of nine silhouettes of different dimensions.

Body dissatisfaction (BD) was calculated through the discrepancy between the silhouettes

chosen by the participant as her actual and desired ones. The questionnaire has good

temporal reliability, as well as good convergent and divergent validities (Thompson &

Altabe, 1991).

Social Comparison Rating Scale (SCRS; Allan & Gilbert, 1995; Gato, 2003). It is

an 11-item scale which evaluates one’s self-perception of social rank in a semantic

differential methodology. The SCRS presents good psychometric properties and negative

correlations with psychopathology.

Social Comparison through Physical Appearance Scale (SCPAS; Ferreira, Pinto-

Gouveia, & Duarte, 2013). The SCPAS assesses the subjective perception based on

physical appearance of women’s social standing and group fit. The participants are asked to

compare themselves with peers (Part A) and with models or other celebrities (Part B). The

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scale revealed high internal consistency in the original study, on both Part A (α = .94) and

Part B (α = .96).

Cognitive Fusion Questionaire-28 (CFQ-28; Gillanders et al., 2010; Pinto-

Gouveia, Dinis, Gregório, & Pinto, 2011). It consists of 28 items, each of them taking the

form of a statement alluding to literality and entanglement with thoughts in order to

measure broad cognitive fusion and defusion. The CFQ-28’s internal consistency values

were good both in the original study and in the Portuguese validation.

Cognitive Fusion Questionnaire - Body Image (CFQ-BI; Ferreira, Trindade, et al.,

2013). The CFQ-BI is a 15-item self-report scale based on the CFQ-28's items so as to

evaluate body image-related cognitive fusion. The CFQ-BI showed good internal

consistency (α = .97), and good temporal, discriminant, convergent and divergent validities

in the original study.

Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003; Gregório &

Pinto-Gouveia, in press). It is a 15-item instrument which evaluates mindfulness

dispositional characteristics. The MAAS was shown to hold strong psychometric qualities

(α = .84 in the original study and .90 in the Portuguese validation).

Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994;

Machado, 2007). The EDE-Q is a self-report measure that assesses attitudes and behavioral

traits of eating disorders. It has demonstrated good reliability and the capacity to

differentiate cases from non-cases of eating disorders (see also Fairburn, 2008).

The Cronbach’s alphas for all of the study variables are reported in Table 1.

3. Results

3.1 Preliminary analyses

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Analysis of Skewness and Kurtosis’ values and visual inspection of the distributions

confirmed the assumption of normality. Preliminary data analyses indicated that this data

was suitable for regression analyses following the assumptions of normality, linearity,

homoscedasticity, independence of errors and multicolinearity (Kline, 1998).

3.2 Descriptive analyses

Descriptive statistics regarding the studied variables for the total sample are

presented in Table 1.

3.3. Correlations

Results demonstrated that the measures of cognitive fusion, CFQ-BI and CFQ_F,

held positive and strong correlations between each other and with higher levels of EDE-Q.

Moreover, those measures held positive correlations with BD (weak in case of the CFQ_F

and moderated in case of the CFQ-BI). Also, these scales showed negative correlations

with MAAS, SCRS and SCPAS. In particular, CFQ-BI correlated positively with BMI (see

table 1).

[insert Table 1 about here]

3.4 Mediation analyses

3.4.1 Body image-related cognitive fusion as a mediator between body dissatisfaction

and eating psychopathology

A regression analysis having BD as the independent variable and EDE-Q as the

dependent variable showed significance [F(1,328) = 173.65, p < .001], explaining 34.6% of

EDE-Q (β = .59, p < .001). The second model (BD as predictor of CFQ-BI) was also

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significant [F(1,329) = 68.99, p <.001], accounting for 17.3% of the variance of CFQ-BI with

a β = .42 (p < .001). The final model, having BD and CFB-BI as independent variables and

EDE-Q as the dependent variable [F(2,327) = 326.40, p < .001], explained 67% of the

variance in eating psychopathology. Also, when the mediator is added, BD’s β is reduced to

.33 (p < .001). The Sobel test (z = 13.13, p < .001) confirmed that CFQ-BI partially

mediates the effect of BD on eating psychopathology severity (Model 1, Figure 1).

[insert Figure 1 about here]

3.4.2 Body image-related cognitive fusion as a mediator between social comparison based

on physical appearance and eating psychopathology

To explore the meditational function of CFQ-BI on the relationship between SCPAS

and EDE-Q the same procedure was conducted.

In the first step (SCPAS predicting EDE-Q), a significant model was obtained [F(1,328)

= 95.91, p < .001], accounting for 23% of EDE-Q (β = -.48, p < .001). In the second step

(SCPAS predicting CFQ-BI), the model was also significant [R2 = .28, F(1,329) = 127.33, p

<.001] with β = -.53 (p < .001). Finally, when SCPAS and CFQ-BI were used as

independent variables, and EDE-Q as the dependent variable, the obtained model [F(2,327) =

230.40, p < .001] explained 59% of the variance of EDE-Q. In this model the predictor’s β

is reduced to -.10 (p = .017). The Sobel test (z = -8.12, p < .001) indicated that CFQ-BI

partially mediates the effect of SCPAS on EDE-Q (Model 2, Figure 1).

4. Discussion and conclusions

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In this study, body image-related cognitive fusion was shown to be positively

associated with broad cognitive fusion as expected (Ferreira, Trindade, et al., 2013), and

with the incapacity of being conscious of the present moment. Indeed, the essence of this

process leads one to lose contact with the present not just in social and physical terms but

also psychologically (Hayes et al., 1999), as individuals fused with their cognitions fail to

observe the content of their thoughts and act automatically to certain events (Hayes, 1989).

Additionally, cognitive fusion concerning body image was linked to unfavorable

social rank perceptions not only when social ranking is based on physical appearance, but

also in a general dimension. Specifically in relation to eating-related symptoms, this study

revealed that cognitive fusion regarding body image is associated with greater body

dissatisfaction and eating psychopathology severity. These results confirm our hypothesis

and add to the existing research showing that the women get are more fused and tangled

with thoughts about their body image, treating them as factual, tend to present more

unfavorable social comparisons, experience higher body dissatisfaction and demonstrate

higher tendencies to engage in disordered eating.

The mediation analyses indicated that body image-related cognitive fusion partially

mediates the relationship of body dissatisfaction and social comparison through physical

appearance towards the severity of eating psychopathology. These results suggest that the

degree to which these factors have an impact on eating psychopathology partially depends

upon on how one is fused with the thoughts about his or her body image. These results

expand preceding research, highlighting how broad cognitive fusion is associated with

disordered eating (e.g., Hayes & Pankey, 2002). They also complement the research

concerning the role of body image dissatisfaction and social comparison through physical

appearance in eating disorders’ vulnerability (e.g. Pinto-Gouveia, Ferreira, & Duarte, 2012;

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Stice et al., 2011). In fact, these results show that neither body dissatisfaction nor

unfavourable social comparison based on physical appearance necessarily underlie

engagement in disordered eating, and that cognitive fusion plays an important role in this

association.

These new findings cannot be considered without taking into account some

limitations. The amount of variables included in the study was intentionally limited in order

to obtain a preliminary comprehension of body image-related cognitive fusion’s impact on

eating psychopathology. Another limitation of the present study was the reliance on a cross-

sectional design which did not allow for casual inferences to be derived. In the future,

longitudinal research should be performed with eating disorders treatment samples in order

to confirm the directionality and predictability of the study variables.

Finally, we believe this study offers significant novel data for research and clinical

work on eating disorders, presenting new empirical support to the interventions focused in

the development of cognitive defusion.

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Note. BMI = Body Mass Index; BD = Body Dissatisfaction (by the FRS); SCRS = Social

Comparison Rating Scale; SCPAS = Social Comparison through Physical Appearance

(with peers and models); CFQ_F = Cognitive Fusion Questionnaire (Fusion Dimension);

CFQ_BI = Cognitive Fusion Questionnaire – Body Image; MAAS = Mindful Attention and

Awareness Scale; EDE-Q = Eating Disorder Examination – Questionnaire (global score).

* p <.050. ** p <.010. *** p <.001.

Table 1

Cronbach’s alphas, Means (M), Standard Deviations (SD), and Intercorrelation scores on

self-report measures (N = 342)

Measures α M SD 1 2 3 4 5 6 7 8

1. BMI - 21.54 8.68 1

2. BD - .56 .94 .57*** 1

3. SCRS .89 65.23 13.72 -.09 -.23*** 1

4. SCPAS

(peers)

.95 61.08 16.34 -.20*** -.32*** .82*** 1

5. SCPAS

(models)

.96 55.25 18.06 -.17** -.37*** .67*** .78*** 1

6. CFQ_F .96 60.36 23.73 .07 .23*** -.37*** -.35*** -.36*** 1

7. CFQ-BI .97 36.35 21.37 .22*** .42*** -.45*** -.53*** -.53*** .69*** 1

8. MAAS .90 60.78 13.55 .05 -.12* .22*** .21*** .24*** -.36*** -.33*** 1

9. EDE-Q .96 1.45 1.33 .39*** .59*** -.36*** -.48*** -.48*** .47*** .76*** -.23***

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Fig. 1. The mediator effect of body image-related cognitive fusion (CFQ-BI). A = the

relation between the independent variable and the mediator, B = the relation between the

mediator and the dependent variable, C = the direct effect of the independent variable on

the dependent variable, C’ = the indirect effect of the independent variable on the

dependent variable controlling for the mediator;

*p<0.05, **p<.01, ***p<.001.